23 June 2010

Focused vs Thorough

I get emails, and one which caught my interest was this recent one from loyal reader Nurse J (lightly edited):

"Do you assess everybody that comes into your ER for everything, or do you just assess the complaint?

I am a newish critical care nurse at A Great Big Hospital, and my wife is a sixth year ICU nurse at a Smaller Hospital. They reviewed a case of an older female who presented with and complained of "flu-like" symptoms. She got treated for said complaint, then also casually mentioned some chest pain......and you know the rest. Stat EKG, ST elevation, elevated cardiac enzymes, and on the way to A Great Big Hospital we go. Only now her door-to-cath lab time was shot.

So, do you only assess to the complaint in the ER? Is that the ER standard? As an ICU nurse, I look at every square inch of my patient at least once or twice a shift, and of course, different patients also require different focused assessments. I loved my rotations in the er, but many times, if the patient seemed stable, I would see nurses not even assess each patient. If you (ER peeps) do have a policy or guideline about only assessing to the chief complaint, then that makes sense. Unless someone is Bleeding, Pulsatingly Bleeding, or has a case of Extra Holes, you don't really need to rush in, the doc will be in in just a minute."
The first thing I would like to draw attention to is the wonderful invention of "Extra Holes" syndrome -- I will be stealing that lovely phrase in the future, I promise you.

As to the general question, the answer is "it depends." We very much tailor the level of the assessment to the patient's complaint and comorbidity. Being an ICU nurse is a very different thing from being an ER provider. (For general discussion, the docs and nurses take similar approaches to assessments in the ER.) When you are working in the ICU you are taking care of a population that is pre-screened to include the sickest and most complex patients that come though the doors, so being compulsive and thorough is essential. It's not surprising that providers habituated to that environment might adopt the position that a comprehensive assessment is the only adequate way to practice: anything else can lead to suboptimal outcomes like the one cited above.

The challenge facing generalists like ER docs and nurses is that we see the unscreened population. We are the first filter. This is where the art of medicine starts to come into play.
It's pretty apparent, of course, that a diabetic presenting with abdominal pain is going to need a detailed and fairly thorough evaluation: there's high risk of a wide variety of Badness and casting a wide net is essential so as not to miss things. On the other hand, it's also obvious that a healthy patient with an ankle sprain needs very little beyond a focused exam of the extremity and a set of vital signs. In fact, when I work fast track, it's common for me to see, treat, and discharge patients before the nurse can even get in the room!

The tweener cases are the ones where we really earn our keep. Consider a common ER presentation: low back pain. 99% of low back pain that we see is trivial -- orthopedic injuries, chronic pain, occasional sciatica. This needs little to no nursing assessment, by and large. I would not criticize a nurse who did not do a comprehensive assessment on such a patient (especially if they were in fast track where I'm in the room first!). But just this month I have had one caudal equina case and one kidney stone presenting as sciatica, and one of my partners had an aortic aneurysm presenting as low back pain. And you need to filter those cases out from the masses of benign presentations: you can't CT scan everybody.

One strategy we use is that of layered evaluations. The first point of contact for a patient is triage, and the triage RN does the first assessment to get a sense of sick-or-not-sick, and risk factors for Badness. Then there is the primary nurse who does a more detailed assessment, then the doctor. At any time there is a possibility the person doing the assessment will redirect the care flow. The chest pain sent back to the cardiac area of the ER might be seen by me and I may cancel all the labs because it's clearly just a broken rib, or conversely, the Fast Track nurse might kick a patient out of Fast Track to a more acute zone if she realizes that this is worse than it was billed initially.

Judgement is essential in this sort of thing. If a patient comes in with, say, a migraine headache, that is really what they need treatment for. If you fail to fix the headache, then you have failed from the patient's perspective. If the patient should mention in your obligatory review of systems that they have had chest pain, you need to understand when you need to chase it and when it's a dead end that you not need to explore. If you drop the headache work-up and chase the bogus chest pain, you'll have a pissed-off patient who doesn't want to be admitted for something that wasn't his primary complaint, even if you do address the headache. On the other hand, sometimes the real problem is kind of buried in the review of systems. I had someone come in for "asthma" who just wanted a refill on his inhaler (he thought). I noticed that he was tachy, not wheezing, and kind of pale. So I did a more complete review of systems on him than I would ordinarily do on a "med refill" patient, and why yes, doctor, my stools have been kind of dark and his hematocrit was 22 due to a bleeding polyp.

In fairness, it was the triage nurse who pointed out that he looked pretty pale!

I try to stay complaint focused -- it's essential in an environment where demand exceeds resources every single day of the week. Otherwise you get bogged down and overwhelmed. It's just as easy to drown in data as it is to miss things by being too cursory. But you need to keep an open mind and be prepared to cast a very wide net -- especially on old ladies with "Flu-like" illnesses!

3 comments:

rxtech1998 said...

Don't you just love the senior citizens who either tell you nothing or their whole life story? They make it difficult to understand what the current complaint is and knowing what tests to run. :)

Nurse J said...

thats a great answer. i think i might forward this to my clinical nurse educators, because i'm kinda sick of hearing them talk bad about our er staff. i can't put it into better words than you have. thank you.

precordialthump said...

Nice insight into the ICU-ER divide.